• You Yuan, Wei Zhong, Huiming Gao, Xia Zhang, Junxi Chen, Yuanqin Qing, and Rujun Hu.
• Department of Critical Care Medicine, Affiliated Hospital of Zunyi Medical University, Zunyi, Guizhou, People's Republic of China.
• Medicine (Baltimore). 2025 Jan 10; 104 (2): e41101e41101.

RationaleEnteral nutrition is a critical component of care for critically ill patients. However, the blind insertion of a nasoenteric tube, despite being a simple procedure, carries inherent risks that necessitate a reevaluation of the technique.Patient ConcernsA case of a 60-year-old female experienced the rare yet critical complication of a misplaced nasoenteric tube entering the thoracic cavity during a blind insertion procedure for enteral nutrition following a liver transplant.DiagnosisFollowing liver transplantation, the patient was diagnosed with severe pneumonia, a right-sided hydropneumothorax, and severe malnutrition.InterventionsAfter the misplacement of the nasoenteric tube into the pleural cavity was detected from the chest X-ray, the tube was immediately removed, and the pneumothorax was actively managed. Subsequently, with the support of contrast radiography, the nasoenteric tube was successfully reinserted to provide the patient with nutritional support and promote rehabilitation.OutcomesThe patient responded well to the intervention and was discharged in stable condition following complete recovery.LessonsThe case prompts a reevaluation of blind placement techniques and calls for the adoption of more reliable technologies to prevent similar incidents and ensure patient safety, such as electromagnetic and visualized guided placement technique.Copyright © 2025 the Author(s). Published by Wolters Kluwer Health, Inc.

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